A Retrospective Analysis of Direct Medical Cost and Cost of Drug Therapy in Hospitalized

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DOI: 10.7860/JCDR/2015/15121.6724 Original Article A Retrospective Analysis of Direct Medical Cost and Cost of Drug Therapy in Hospitalized

Pharmacology Section Patients at Private Hospital in Western India

Prakash R Shelat1, Shivaprasad Kalakappa Kumbar2

ABSTRACT than 45 year age group. They were divided into medical and Background: Pharmacoeconomics is analytical tool to know surgical patients according to their admission in medical or cost of hospitalization and its effect on health care system surgical ward. Mortality, Intensive Care Unit (ICU) admission, and society. In India, apart from the government health patients on ventilator were significantly (p<0.05) higher in services, private sector also play big role to provide health care medical patients. Direct medical cost, ward bed charge, ICU services. bed charge, ventilator charge and cost of drug therapy per patient were significantly (p<0.05) higher in medical patients Objective: To study the direct medical cost and cost of drug while operation theatre and procedural charge were significantly therapy in hospitalized patients at private hospital. (p<0.05) higher in surgical patients. Cost of fibrinolytics, Materials and Methods: A retrospective study was conducted anticoagulants, cardiovascular drugs were significantly (p<0.05) at private hospital in a metro city of Western India. Total 400 higher in medical patients. Cost of antimicrobials, proton pump patients’ billing records were selected randomly for a period inhibitors (PPIs), antiemetics, analgesics, were significantly from 01/01/2013 to 31/12/2014. Data were collected from (p<0.05) higher in surgical patients. medical record of hospital with permission of medical director Conclusion: Ward bed charge, ICU bed charge, ventilator of hospital. Patients’ demographic profile age, sex, diagnosis charge accounted more than one third cost of direct medical and various costs like ICU charge, ventilator charge, diagnostic cost in all the patients. Cost of drug therapy was one fourth of charge, etc. were noted in previously formed case record form. direct medical cost. Antimicrobials cost accounted 33% of cost Data were analysed by Z, x2 and unpaired t-test. of drug therapy. Result: Patients were divided into less than 45 years and more

Keywords: Charge, Cost, Intensive care Unit (ICU), Ward

Introduction randomly from patient registration number. Data like age, gender, Pharmacoeconomics is analytical tool to know cost of hospitalization admission in medical or surgical ward, outcome of patient, cost and its effect on health care system and society [1]. Cost of of hospitalization including investigation charge, doctor consulting hospitalization includes direct medical cost, indirect cost and charge, ICU charge etc. were recorded in preformed case record intangible cost. Cost of hospital bed charge, laboratory charge, form. Direct medical cost, total cost of drug therapy and cost of diagnostic charge, doctor consulting charge, etc. were included in group of drugs were calculated. Charges of hospitalization was direct medical cost [1]. converted from Indian to United States currency (`62.19 INR = 1$ USD) exchange rate as per on date on 02/04/2015 available from In India, apart from the government health services, private sector official Reserve Bank of India’s website. The data were analysed at also play big role to provide health care services. Government of India the end of study by Z, x2 and unpaired t-test. reported that the private sector delivers about 60% of all inpatient care [2]. In India, during hospitalization 80% patients have to pay out of their pocket for health care service due to lack of insurance RESULTS cover and more than 40% admitted patient had to borrow money Total 400 patients’ billing record were collected and studied. Patients or sell their assets [3]. were divided into medical and surgical patients according to their Information about cost of hospitalization is helpful for policy makers Demographic data Medical Patients Surgical Patients Total Patients to allocate better health facilities and services [4]. It is also helpful in n=237 (%) n=163 (%) n=400 (%) developing country for reimbursement of social security system [5]. Age> 45 years 174(73.41)# 99 (60.73)# 273(68.25)# There is lack of data about direct medical cost of hospitalization in Age ≤ 45 years 63(26.59) 64(39.27) 127(31.75) admitted patients at private hospital in Western India. Hence we Male 127(53.58)@ 108(66.25)@ 235(58.75)@ carried out this study to analyze direct medical cost of hospitalization Female 110(46.42) 55(33.75) 165(41.25) and cost of drug therapy in admitted patients at private hospital in a Mortality 84(35.44)* 41(25.77) 123(30.75)* metro city of Western India. Patients on ventilator 92(38.81)* 38(23.31) 130(32.5)* ICU admission 124(52.32)* 68(41.17) 192(48)* MATERIALs AND METHODS Duration of stay in 8.37±2.16** 6.41±2.23 7.57±2.03** hospital (days) The study was retrospective syudy conducted at one private Procedure (surgical/ 46(19.4) 98(60.12)& 144(36)& hospital in metro city of Western India. A study approval was diagnostic) taken from medical director of hospital after assurance to maintain [Table/Fig-1]: Analysis of demographic data of patients (n=400) confidentiality of patients and hospital. To know direct medical cost, *p <0.05 (z-test) significantly higher as compared to surgical patients **p <0.05 (t-test) significantly higher as compared to surgical patients investigator collected data of 400 admitted patients’ billing record &p<0.05 (z-test) significantly higher as compared to medical patients #p <0.05 (X2 test) significantly higher as compared to age≤ 45 years for a period of 01/01/2013 to 31/12/2014. Data was selected @p <0.05 (X2 test) significantly higher as compared to female

Journal of Clinical and Diagnostic Research. 2015 Nov, Vol-9(11): FC09-FC12 9 Prakash R Shelat and Shivaprasad Kalakappa Kumbar, Direct Medcial Cost in Hospitalized Patients www.jcdr.net

(p<0.05) higher in medical patients as compared to surgical patients [Table/Fig-1]. Out of 400 patients it was observed that 98 (60.12%) patients admitted for surgical procedures (for appendicitis, gall stone, peptic perforation etc), 88(37.13%) patients admitted for cardiovascular disorder (CHF, LVF, IHD) and 63 (26.58%) patients admitted for Central Nervous System (CNS) disorder, CV stroke [Table/Fig-2].

Analysis of direct medical cost of hospitalization Ward bed charge, ICU bed charge and ventilator charge per patient were significantly (p<0.05) higher in medical patients as compared to surgical patients while Operation Theatre (OT) charge and procedural charge were significantly (p<0.05) higher in surgical patients as compared to medical patients. Consultation charge per patient and total cost of drug therapy were significantly (p<0.05) higher in medical patients as compared to surgical patients. Direct medical cost of hospitalization was significantly (p<0.05) higher in medical patients as compared to surgical patients [Table/Fig-3].

Cost of drug therapy [Table/Fig-2]: Analysis of diagnosis of patients (n=400) The cost of drug therapy per patient was calculated. Cost of drug (CHF=Congestive Heart Failure, LVF- Left Ventricular Failure, IHD- Ischemic Heart Disease COPD- therapy per patient in above 45 years age was significantly (p<0.05) Chronic Obstructive Pulmonary Disease) higher as compared to below 45 years age. It was observed that

Group Medical Surgical Total Patients cost of drug therapy per patient in survived cases and patients on Patients Patients (n=400) (n=237) (n=163) Mean±SD ventilator support were significantly (p<0.05) higher as compared Mean±SD Mean±SD expired cases and patients without ventilator support [Table/ Cost of therapy per patient `11831±2876*# `8872± 2098 `10625±2258* Fig-4]. Cost of fibrinolytics, anticoagulants, inotropes, antiepilepics/ age >45 $190±46 $142±33 $170±36 sedatives, cardiovascular drugs, respiratory drugs, diuretics, Cost of therapy per patient `4375± 1785 `4454± 2102 `4407±2056 antidiabetic drugs, anticholinergic drugs were significantly (p<0.05) in age ≤45 $70±28 $71±33 $70±33 higher in medical patients as compared to surgical patients. Cost Cost of therapy per patient `10354±2042*# `9231± 1587 `9856±2174* of antimicrobials, IV fluids/Plasma expander, PPIs, antiemetics, in survived cases $166±32 $148±25 $159±34 analgesics, were significantly (p<0.05) higher in surgical patients as Cost of therapy per patient `5852± 2346*# `4095± 2537 `5136±2203* compared to medical patients [Table/Fig-5]. in expired cases $94±37 $65±40 $82±35 Cost of therapy per patient `10482±2874*# `8364± 2162 `9619±2332* DISCUSSION on ventilator $168±46 $137±35 $154±35 In our study more than 60% patients were above 45 years age * * Cost of therapy per patient `5724± 2034 `4762± 2130 `5413±2146 group. It may be due to life threatening diseases like cardiovascular on without ventilator $92±32 $76±34 $87±34 [Table/Fig-4]: Analysis of cost of drug therapy according to ventilator support and diseases, respiratory infection, diabetes and traumatic injury which outcome basis (n=400) are common in above 45 years age group which may required (Cost expressed in `Indian Rupee converted in $ US dollar) hospitalization. In our study male patients were significantly higher * p <0.05 (t-test) significantly higher as compared to surgical patients ** p <0.05 (t-test) significantly higher as compared to medical patients as compared to female patients. Roy et al., reported that due to # p <0.05 (t-test) significantly higher as compared to total patients social status and economic dependence women did not get better admission into medical or surgical ward respectively. Patients’ age health care facilities as compared to male [6]. Similar report of above 45 years significantly (p<0.05) higher as compared to less gender disparity in use of health care service also observed in China than 45 years. Male patients were significantly (p<0.05) higher as and Nigeria [7,8]. It is concern for our society and government to compared to female patients. Mortality and average duration of look after and provide health care service to women. Mortality was stay, ICU admission, patients on ventilator support were significantly significantly higher in medical patients (34%) as compared to surgical

10 Journal of Clinical and Diagnostic Research. 2015 Nov, Vol-9(11): FC09-FC12 www.jcdr.net Prakash R Shelat and Shivaprasad Kalakappa Kumbar, Direct Medcial Cost in Hospitalized Patients

Group Medical Patients % of Surgical Patients % of Total Patients % of (n=237) Mean±SD total (n=163) Mean±SD total (n=400) Mean±SD total Cost in Cost in cost Cost in Cost in cost Cost in Cost in cost Indian US dollar Indian US dollar Indian US dollar Rupee Rupee Rupee Antimicrobials `4672±2462 $75±39 28.83 `5356±3478** $86±55 40.19 `4951±2826 $79±45 32.94 Fibrinolytics `2862±1478*# $46±23 17.66 `824±568 $13±9 6.18 `2032±1674* $32±26 13.52 Anticoagulant `1236±984* $19±15 7.63 `926±742 $14±11 6.94 `1109±918* $17±14 7.38 Antiepileptic/ Sedatives `1204±714*# $19±11 7.43 `654±498 $10±8 4.91 `980±746* $15±11 6.52 IV fluids/ Plasma expander `837±563 $13±9 5.16 `934±762** $15±12 7.01 `877±643 $14±10 5.83 Inotropes `1033±846*# $16±13 6.37 `648±464 $10±7 4.86 `875±710* $14±11 5.82 Analgesics `735±459 $11±7 4.54 `1024±832**# $16±13 7.69 `853±584** $13±9 5.67 Proton Pump Inhibitors `578±320 $9±5 3.56 `964±712**# $15±11 7.24 `735±512** $11±8 4.89 Cardiovascular drugs `834±692*# $13±11 5.15 `234±142 $3±2 1.76 `589±394* $9±6 3.92 Antiemetics `422±318 $6±5 2.61 `682±514**# $10±8 5.12 `528±402** $8±6 3.51 Respiratory drugs `624±486*# $10±7 3.85 `312±172 $5±2 2.34 `497±264* $7±6 3.3 Antidiabetic drugs `428±316*# $6±5 2.64 `124±98 $1±1 0.93 `304±172* $4±2 2.02 Diuretics `324±164*# $5±2 1.99 `104±82 $1±1 0.78 `234±174* $3±2 1.56 Anticholinergics `215±135*# $3±2 1.33 `128±76 $2±1 0.96 `180±114* $2±1 1.2 Others `202±108 $3±1 1.25 `412±214**# $6±3 3.09 `288±168** $4±2 1.92 [Table/Fig-5]: Analysis of cost of drug therapy among various drug groups (n=400) (Cost expressed in `Indian Rupee converted in $ US dollar) * p <0.05 (t-test) significantly higher as compared to surgical patients ** p <0.05 (t-test) significantly higher as compared to medical patients # p <0.05 (t-test) significantly higher as compared to total patients patients (25%). Patients on ventilator were significantly higher in patient duration of stay in ward or ICU in hospital affect consulting medical patients (38%) as compared to surgical patients (23%). cost. Total cost of investigation of per patient was more than `2500 Mukhopadhyay et al., reported that mortality was higher in patient in our study which was lower to `25,030 reported by Pattanaik S et on ventilator due to critically illness as well as cardio respiratory al., [17]. It may be due to they include intervention procedure cost complication [9]. Average duration of stay was significantly (p<0.05) while we include only investigation cost. higher in medical patients as compared to surgical patients. In Direct medical cost of hospitalization was significantly higher in medical patients co-morbid condition was highly observed while medical patients as compared to surgical patients. It may be due surgical patients were admitted for postoperatively observation. to cost of ICU care was higher in medical patients as compared to In direct medical cost, ward bed charge, ICU bed charge and surgical patients. Dror et al., reported that cost of hospitalization ventilator charge per patient were significantly higher in medical was `1405±151 in private hospital which was lower as compared patients while in USA it was higher in surgical patients [10]. Dasta et to our study [18]. It may be due to study location of both studies as al., reported that cost per patient on ventilator was $31,574±42,570 our study was at private hospital in metro city while their study was which was higher as compared to our ventilator cost per patient five resource poor locations in India. ($103±60) [11]. Parikh et al., reported that cost per patient per day Cost of drug therapy per patient was `16206±3286 ($260±52) in in ICU was `1,973 (U.S. $57) which was lower as compared to medical patients which was significantly higher as compared to our ICU bed cost per patient (`15325±9825) [12]. It may be due surgical patients where it was `13326±2486 ($214±39). Both were to their study conducted in 1999 while our study was conducted a lower as compared to `19,725 reported by Biswal et al., [19]. Data period of 2013-14. Ward bed charge, ICU bed charge and ventilator from the western literature reported drug costs per patient-day charge were accounted 47% of direct medical cost. It suggested ranging from $208 to $312 which was similar to our study [20]. that cost of ICU care in direct medical cost was higher and create Cost of drug therapy was 25% of direct medical cost in our study more financial burden to patients. ICU care cost has major part in which was lower to 74% reported by Chatterjee et al., [21]. It may direct medical cost during hospitalization as various newer machine be due to different cost methodology used in both studies. Cost of and ventilator charge accounted in the ICU care cost. drug therapy in our study was similar to western countries. It will In surgical patients cost of OT per hour per patient was `3776±2631 affect utilization of health care service for our people as there is less which was lower to compared to both studies by Singh M et al., medical insurance penetration as compared to western countries. and Siddarth V et al., where per hour OT cost was `11948 and Cost of drug therapy per patient in survived cases was above `22626 respectively [13,14]. It may be due to different patient profile `9000 in our study which was higher ascompared to Patel MK and different surgical procedure which required different operation et al., (`2932.36) [22]. It may be due to survival rate was 21% in theatre. Chatterjee S et al., reported that unit cost of operative their study while it was 70% in our study [22]. Cost of fibrinolytics, procedure was `27,236 in private hospital which was higher anticoagulants and inotropics were significantly higher in medical as compared to operative cost of surgical patients where it was patients and accounted 31% of cost of drug therapy in medical `9500±6408 [15]. It may be due to number of surgical procedure patients. Patel BJ et al., and Patel MK et al., reported that cost of in our study was 96 while it was 2058 in their study. By comparing inotropic agents per patient was `262 and `408 respectively which average cost of procedure among different hospital, it will be helpful was lower compared to our study (`875±710) [22,23]. Patient of for hospital administration to monitor the operation cost for better IHD, pulmonary embolism were admitted in medical ward and in resource utilization. OT charge and procedural charge accounted these patient inotropes, fibrionolytics and anticoagulant were used. 23% of direct medical cost during hospitalization in surgical patients. Cost of PPIs, antiemetics, analgesics were above $10 in surgical Our study revealed that OT charge and procedural charge has patients which was lower to reported by Kaur S et al., where they greater contribution in direct medical cost in surgical patients. were above $70 [24]. These three drugs accoutend 20% of cost of Consultation cost per patient was above `3700 in all patients which drug therapy in surgical patients. Pantoprazole is useful in preventing was higher as compared to Kumpatla et al., where it was `1050 bleeding and analgesics to reduce and treat postoperative pain [16]. This may be due to different consulting charge of doctor while antiemetics were commonly prescribed to prevent nausea among different hospital in different location of country as well as and vomiting in postoperative patients.

Journal of Clinical and Diagnostic Research. 2015 Nov, Vol-9(11): FC09-FC12 11 Prakash R Shelat and Shivaprasad Kalakappa Kumbar, Direct Medcial Cost in Hospitalized Patients www.jcdr.net

Cost of antimicrobials per patient was `5356±3478 ($86±55) in [3] Jayaram R, Ramakrishnan N. Cost of intensive care in India. Indian J Crit Care surgical patients which was significantly higher as compared to Med. 2008;12(2):55-61. [4] Green A, Ali B, Naeem A, Vassall A. Using costing as a district planning and medical patients. In surgical patients antimicrobials were prescribed management tool in Balochistan, Pakistan. Health Policy Plann. 2001;16:180– to prevent and treatment of infections. Study conducted at Nepal 86. reported that cost of antimicrobials per patient was $16.5±13.4 [5] Adam T, Evans D. Determinants of variation in the cost of inpatient stays versus outpatient visits in hospitals: a multi country analysis. Soc Sci Med. which was lower as compared to our study [25]. Daily antimicrobial 2006;63:1700–10. cost was €114 and $89 in Belgium and Turkey respectively [26,27]. [6] Roy K, Chaudhuri A. Influence of socioeconomic status, wealth and financial Both were higher as compared to our study. In our study cost of empowerment on gender differences in health and healthcare utilization in later antimicrobials was 33% of total drug cost in all patients which was life: evidence from India. Soc Sci Med. 2008;66:1951-62. [7] Kolo P, Chijioke A. Gender Disparities in Mortality among Medical Admissions of a lower to 72.3% reported by Williams P et al., [28]. Antimicrobial cost Tertiary Health Facility in Ilorin, Nigeria. The Internet Journal of Tropical Medicine. accounted more in total cost of drug therapy due to its inappropriate 2008;16:25-32. and irrational use during hospitalization. So, specific guideline [8] Bian Y, Song Y. Gender differences in the use of health care in China: cross- should be made for rational, affordable use of antimicrobials during sectional analysis. International Journal for Equity in Health. 2014;13:8. [9] Mukhopadhyay C, Bhargava A, Ayyagari A. Role of mechanical ventilation & hospitalization. development of multidrug resistant organisms in hospital acquired pneumonia. In our study ward bed charge, ICU bed charge, ventilator charge Indian J Med Res. 2003;118:229-35. [10] Frezza EE, Squillario DM, Smith TJ. The ethical challenge and the futile treatment accounted one third of direct medical cost of hospitalization and in the older population admitted to the intensive care unit. Am J Med Qual. cost of drug therapy accounted one fourth of cost of direct medical 1998;13(3):121-26. cost in all the patients. Antimicrobials accounted 33% of total [11] Dasta JF, et al. Daily cost of an intensive care unit day: The contribution of drug cost in total patients. Our study will be helpful for hospital mechanical Ventilation. Critical care medicine. 2006;33(6):1266-71. [12] Parikh CR, Karnad DR. 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The Costs of Treating limitation Long Term Diabetic Complications in a Developing Country: A Study from India. Our study limitation, we did not calculate indirect cost like transport JAPI. 2013;61:102-09. cost, loss of wages, medical equipment cost, staff salary cost. [17] Pattanaik S, Dhamija P, Malhotra S, Sharma N, Pandhi P. Evaluation of cost of treatment of drug-related events in a tertiary care public sector hospital in Further we did not include tertiary teaching care hospital, charitable Northern India: a prospective study. Br J Clin Pharmacol. 2009;67(3):363–69. trust hospital and other corporate hospital. Our study is a preliminary [18] Dror DM, Putten-Rademaker OV, Koren R. Cost of illness: Evidence from a study study on hospital costing in private hospital in Western India. In in five resource-poor locations in India.Indian J Med Res. 2008;127:347-61. account of the size and diversity of our country and charge variations [19] Biswal S, Mishra P, Malhotra S, et al. Drug utilization pattern in the intensive care unit of a tertiary care hospital. J Clin Pharmacol. 2006;46:945-51. across hospitals further large size study should be undertaken to [20] Weber RJ, Kane SL, Oriolo VA, Saul M, Skledar SJ, Dasta JF. Impact of intensive know better understanding of hospital costing. It provides more care drug costs: A descriptive analysis, with recommendations for optimizing comprehensive information to hospital administration and policy ICU pharmacotherapy. Crit Care Med. 2003;31:17-24. [21] Chatterjee S, Levin C, Laxminarayan R. Unit cost of medical services in different makers for policy purposes. hospitals in India. PLOS ONE. 2013;8(7):1-10. [22] Patel MK, Barvaliya MJ, Patel TK, Tripathi CB. Drugutilization pattern in critical CONCLUSION care unit in a tertiary care teaching hospital in India. Int J Crit Illn Inj Sci. In conclusion, our study reveals that ward bed charge, ICU bed 2013;3:250-55. [23] Patel BJ, Patel KH, Trivedi HR. 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Links Daily cost of antimicrobial therapy in patients with Intensive Care Unit-acquired, laboratory-confirmed bloodstream infection. Int J Antimicrob Agents. 2008;31:161-65. References [27] Inan D, Saba R, et al. Daily antibiotic cost of nosocomial infections in a Turkish [1] Sanchez LA. Pharmacoeconomics. In: Dipiro JT, Talbent RL, editors. university hospital. BMC Infect Dis. 2005;5:5. Pharmacotherapy. A pathophysiological approach. 6th ed. New Delhi: The [28] Williams A, Mathai AS, Phillips AS. Antibiotic prescription patterns at admission McGraw-Hill; 2002:1-16. into tertiary level intensive care unit in Northern India. J pharm Bioall Sci. [2] Government of India. New Delhi: Ministry of Health and Family Welfare. Annual 2011;3:531-36. report to the people on health 2010.

PARTICULARS OF CONTRIBUTORS: 1. Assistant Professor, Department of Pharmacology, P.D.U. Govt. Medical College, Rajkot, Gujarat, India. 2. Assistant Professor, Department of Pharmacology, BLDEU’s Shri B. M. Patil Medical College, Bijapur, Karnataka, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Prakash R Shelat, E 28 Government Medical Quarter High Rise Tower Jamnagar Road Rajkot, Gujarat-360001, India. Date of Submission: Jun 05, 2015 E-mail: [email protected] Date of Peer Review: Jul 28, 2015 Date of Acceptance: Sep 22, 2015 Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Nov 01, 2015

12 Journal of Clinical and Diagnostic Research. 2015 Nov, Vol-9(11): FC09-FC12